There have been significant technological and technical advances in radiotherapy over the last 20... more There have been significant technological and technical advances in radiotherapy over the last 20 years. This paper presents the pertinent advances and examines their application in contemporary breast cancer (BC) radiotherapy, particularly for reducing the long-term toxicity, using intensity-modulated radiation therapy, image-guided radiation therapy, and management of breathing motion. These modern technologies and techniques enable precise delivery of a highly conformal radiation dose distribution to the target volume in real-time, to optimise tumour control, and minimise treatment toxicity. They have been used for the treatment of BC in selected centres around the world. Although there is insufficient high-level evidence to support their routine application in BC at present, implementation of these technologies has been shown to be feasible, and could result in clinically meaningful long-term benefits for selected patients with BC.
Background and purpose: Accurate quantification of the relatively small radiation doses delivered... more Background and purpose: Accurate quantification of the relatively small radiation doses delivered to untargeted regions during breast irradiation in patients with breast cancer is of increasing clinical interest for the purpose of estimating long-term radiation-related risks. Out-of-field dose calculations from commercial planning systems however may be inaccurate which can impact estimates for long-term risks associated with treatment. This work compares calculated and measured dose out-of-field and explores the application of a correction for leakage radiation. Materials and methods: Dose calculations of a Boltzmann transport equation solver, pencil beam-type, and superposition-type algorithms from a commercial treatment planning system (TPS) were compared with in vivo thermoluminescent dosimetry (TLD) measurements conducted out-of-field on the contralateral chest at points corresponding to the thyroid, axilla and contralateral breast of eleven patients undergoing tangential beam radiotherapy for breast cancer. Results: Overall, the TPS was found to under-estimate doses at points distal to the radiation field edge with a modern linear Boltzmann transport equation solver providing the best estimates. Application of an additive correction for leakage (0.04% of central axis dose) improved correlation between the measured and calculated doses at points greater than 15 cm from the field edge. Conclusions: Application of a correction for leakage doses within peripheral regions is feasible and could improve accuracy of TPS in estimating out-of-field doses in breast radiotherapy.
International Journal of Radiation Oncology*Biology*Physics, 2001
Purpose: Axillary dissection (AD) provides staging information and guides adjuvant treatment for ... more Purpose: Axillary dissection (AD) provides staging information and guides adjuvant treatment for patients with breast cancer. The impact of AD on breast cancer survival is unclear. This study examines age-related variations in the use of AD and analyzes survival in women with T1-T2 breast cancer according to age and AD use. Data from the Breast Cancer Outcomes Unit database was analyzed for 7,134 women aged 50ϩ referred to the British Columbia Cancer Agency from 1989-1998 with invasive T1-T2, M0 breast cancer. Primary tumor characteristics and systemic therapy use were compared using chi-square tests for women who were treated with vs without AD (ADϩ vs AD-) according to three age groups: 50-64, 65-74, and 75ϩ. Five-year actuarial breast cancer specific and overall survival were calculated using life table analysis. Comparisons of survival between ADϩ vs AD-patients were performed using Wilcoxon statistics. Results: Among 7,134 women, 47% (nϭ3,329) were aged 50-64, 34% (nϭ2,434) were aged 65-74, and 19% (nϭ1,371) were aged 75ϩ. AD was performed in 91% (nϭ6,485) of all patients. AD was omitted more frequently with advancing age (4% vs 9% vs 22% in women aged 50-64, 65-74 and 75ϩ respectively, pϽ.001). Tumor Characteristics in AD-vs ADϩ Patients: Among women aged 50-64, AD-and ADϩ patients had similar distributions of T2 tumors (29% vs 35%, pϭ.21) and grade III disease (33% vs 37%, pϭ.20). Among women in the older age groups, AD-patients had fewer T2 tumors (age 65-74: 20% T2 vs 32% T2, pϽ.001 and age 75ϩ: 27% T2 vs 40% T2, pϽ.001) and were less likely to have grade III disease (age 65-74: 21% gIII vs 32% gIII, pϽ.001 and age 75ϩ: 18% gIII vs 27% gIII, pϭ.001). Lymphovascular invasion was found less frequently in AD-patients: (age 50-64: 25% vs 35%, pϭ.03, age 65-74: 16% vs 32%, pϽ.001, and age 75ϩ: 24% vs 30%, pϭ.04). Estrogen receptor positivity was similar between ADand ADϩ patients (age 50-64: 82% vs 76%, pϭ.18, age 65-74: 85% vs 81%, pϭ.11, and age 75ϩ: 88% vs 86%, pϭ.29). Systemic Therapy Use: Overall, 42% did not receive any systemic therapy, 42% received Tamoxifen only, 7% received chemotherapy only, and 8% received both Tamoxifen and chemotherapy. The proportions of AD-and ADϩ patients who received systemic therapy were: age 50-64: 53% vs 60%, pϭ.36, age 65-74: 57% vs 56%, pϭ.73, and age 75ϩ: 57% vs 54%, pϭ.32. Clinical Outcome: Five-year actuarial breast cancer specific survival and overall survival according to age and AD use are summarized in Table . Actuarial breast cancer specific survival was lower in AD-women aged 65-74 (82% vs 88%, pϭ.04) but was similar in AD-and ADϩ women aged 50-64 and 75ϩ. Actuarial overall survival was lower in AD-vs ADϩ women in all three age groups: age 50-64: 80% vs 86%, pϭ.06, age 65-74: 68% vs 82%, pϭ.0004, and age 75ϩ: 60% vs 68%, pϭ.03. Axillary dissection was more frequently omitted with advancing age. The omission of AD did not impact breast cancer specific survival in women aged 50-64 or aged 75ϩ but was associated with lower breast cancer specific survival in women aged 65-74 despite similar rates of systemic therapy use.
Background This study compared the application of the St Gallen 2001 classification with a risk i... more Background This study compared the application of the St Gallen 2001 classification with a risk index developed at the New South Wales Breast Cancer Institute (BCI Index) for women with node-negative breast cancer treated without adjuvant systemic therapy. Methods The BCI risk categories were constructed by identifying combinations of prognostic indicators that produced homogeneous low-, intermediate- and high-risk groups using the same variables as in the St Gallen classification. Results The BCI low-risk category consisted of women aged 35 years or more with a grade 1 oestrogen receptor (ER)-positive tumour 20 mm or less in diameter, or with a grade 2 ER-positive tumour of 15 mm or less. This category constituted 40·1 per cent of patients, with a 10-year distant relapse-free survival (DRFS) rate of 97·2 per cent. The BCI intermediate-risk category included women aged 35 years or more with a grade 2 ER-positive tumour of diameter 16–20 mm, or a grade 1 or 2 ER-negative tumour measu...
Background The 1998 St Gallen classification was devised to guide clinicians in the use of adjuva... more Background The 1998 St Gallen classification was devised to guide clinicians in the use of adjuvant systemic therapy for women with early breast cancer. In this study, the classification was applied to a historical group of patients with node-negative breast cancer who were treated without adjuvant therapy. Methods The St Gallen classification was applied to 421 women with breast cancer treated with conservative surgery and radiotherapy alone between 1979 and 1994. Primary tumour characteristics were reviewed centrally. Results When the most stringent version of the St Gallen classification was applied (grade 2 or 3 tumours classified as ‘high risk’), only 10 per cent of patients were ‘low risk’, with a 10-year distant relapse-free survival (DRFS) rate of 100 per cent, and 15 per cent were at ‘intermediate risk’ (10-year DRFS rate of 94 per cent). The high-risk group (75 per cent of women) had a 10-year DRFS rate of 77 per cent (P < 0·01). If the St Gallen classification had been...
Rates and risk factors of local, axillary and supraclavicular recurrences can guide patient selec... more Rates and risk factors of local, axillary and supraclavicular recurrences can guide patient selection and target for postmastectomy radiotherapy (PMRT). Patients and methods: Local, axillary and supraclavicular recurrences were evaluated in 8106 patients enrolled in 13 randomized trials. Patients received chemotherapy and/or endocrine therapy and mastectomy without radiotherapy. Median follow-up was 15.2 years. Results: Ten-year cumulative incidence for chest wall recurrence of >15% was seen in patients aged <40 years (16.1%), with ≥4 positive nodes (16.5%) or 0-7 uninvolved nodes (15.1%); for supraclavicular failures >10%: ≥4 positive nodes (10.2%); for axillary failures of >5%: aged <40 years (5.1%), unknown primary tumor size (5.2%), 0-7 uninvolved nodes (5.2%). In patients with 1-3 positive nodes, 10-year cumulative incidence for chest wall recurrence of >15% were age <40, peritumoral vessel invasion or 0-7 uninvolved nodes. Age, number of positive nodes and number of uninvolved nodes were significant parameters for each locoregional relapse site. PMRT to the chest wall and supraclavicular fossa is supported in patients with ≥4 positive nodes. With 1-3 positive nodes, chest wall PMRT may be considered in patients aged <40 years, with 0-7 uninvolved nodes or with vascular invasion. The findings do not support PMRT to the dissected axilla.
European journal of cancer (Oxford, England : 1990), Jul 7, 2016
Although the benefit of adjunct digital breast tomosynthesis (DBT) is established in population s... more Although the benefit of adjunct digital breast tomosynthesis (DBT) is established in population screening, its benefit in surveillance after breast cancer treatment is not well defined. We prospectively evaluated whether the addition of DBT to digital mammography (DM) reduced the rate of indeterminate findings compared to DM alone in patients after breast cancer treatment. Patients had both DM and DBT for routine surveillance. Two-dimensional synthesised mammogram (SM) was generated for each patient from DBT data. DM, SM, and DBT images were read for each patient by one of four radiologists credentialed for DBT. We compared the rates of indeterminate findings between DM+DBT with DM alone in patients with a range of breast densities and between DM and SM. A total of 618 patients and 1069 breasts were analysed. The rates of indeterminate findings for DM+DBT versus DM alone were 10.5% and 13.1%, respectively (p=0.018). In breasts treated with surgery and radiotherapy (n=558), the corre...
To analyze the acute, late toxicity and esthetic outcome in early breast cancer patients treated ... more To analyze the acute, late toxicity and esthetic outcome in early breast cancer patients treated with hypofractionated radiotherapy (H-RT) preceded by IORT or followed by sequential boost (SB). Materials and Methods: 129 women with invasive breast cancer stages I and II received H-RT, 42.40 Gy (2.65Gy x 16 #) preceded by IORT (10 Gy in single fraction) in 53 patients (IORT/H-RT) or followed by SB (10 Gy-2.50 Gy x 4 #) in 76 patients (H-RT/SB). RTOG/EORTC toxicity scales were used to score acute and late skin toxicity and ultrasound analysis to assign a value to skin thickening. Cosmetic outcome was assessed comparing treated with untreated breast. Results: Acute skin toxicity of Grade 1, 2 or 3 was experienced by 58.5%, 3.7% and 0% of IORT/H-RT versus 67.1%, 9.2% and 1.3% of H-RT/SB patients. After an average of 26.5 months, late skin toxicity of Grade 1 or 2 was experienced by 34% and 1.8% of IORT/H-RT versus 42.2% and 7.8% H-RT/SBpatients. Skin thickening was greater in H-RT/SB (35.3%) than in IORT/H-RT group (8.1%). Long term cosmetic outcome was excellent or good in 94.3% of IORT/H-RT and in 72.3% of H-RT/SB patients. Results were statistically significant(p<0.001). Conclusions: Respect to SB, IORT reduces the acute and late skin toxicity, improving the subjective perception of the cosmetic outcome in early breast cancer patients treated with H-RT. EP-1213 Unintended irradiation of internal mammary chain-is that enough?
Canadian journal of surgery. Journal canadien de chirurgie, 2003
Because there is no standardized technique for mapping of lymph nodes and no optimal technique fo... more Because there is no standardized technique for mapping of lymph nodes and no optimal technique for evaluating the sentinel node, we decided to evaluate practice patterns for sentinel-node biopsy (SNB) for breast cancer in British Columbia 5 years after its introduction in 1996. We carried out mail and telephone surveys of general surgeons performing at least 1 SNB (n = 28) or not performing SNB (n = 50), and carried out telephone surveys or on-site visits with pathologists (n = 7) and nuclear medicine physicians (n = 5) from institutions supporting SNB in the province. We collected data on training, perceived indications and techniques for the surgical, imaging and pathologic assessments of SNB to obtain data on practice patterns in 2001 and the degree of consistency among surgeons and institutions involved in performing SNB and reasons for not adopting the SNB technique. By 2001, SNB was incorporated into the practice of 19% of surgeons (28 of 150) performing breast cancer surgery ...
The purpose of this article was to review the patterns and morbidity of regional recurrence (RR) ... more The purpose of this article was to review the patterns and morbidity of regional recurrence (RR) in patients with early breast cancer, efficacy of salvage therapy for RR, and complications of regional nodal treatment. A retrospective evaluation of 1,158 patients with stage I or stage II breast cancer treated with conservative surgery and radiotherapy (RT) between 1979 and 1994 was performed. Seven hundred fifty patients underwent axillary surgery, and 229 patients received RT as their only treatment of the regional lymphatics. Regional nodal RT was given to 168 patients who also had axillary surgery. The regional lymphatics of 11 patients were not treated. The patterns and morbidity of RR, relapse management, and complications related to regional nodal treatment were reviewed from the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; records. With a median follow-up of 88 months, a total of 31 patients (2.7%) developed a RR. Nine of 31 patients (29%) with an RR experienced significant morbidity, including pain, fungating tumor, dysphagia, dyspnoea, and/or sensory motor changes at diagnosis. Nineteen patients (61%) had symptomatic residual or progressive regional disease after salvage therapy at last follow-up or death. Six of nine patients (67%) who developed an isolated axillary recurrence and underwent salvage surgery had no further axillary recurrence. The addition of regional nodal RT to breast irradiation significantly increased the incidence of symptomatic pneumonitis (1% without regional nodal RT and 4% with regional nodal RT, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Combined axillary dissection and nodal irradiation resulted in a significantly higher incidence of arm edema compared with either alone (9.5% with axillary dissection, 6.1% with RT to the axilla and supraclavicular fossa, and 31% with combined modality therapy, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Five of 380 patients (1%) who received RT to the axilla and/or supraclavicular fossa developed a transient brachial plexus neuropathy. Although RR was uncommon in patients treated with axillary surgery and/or regional nodal irradiation, salvage therapy failed to eradicate the recurrence in approximately two thirds of the patients with a RR. Ongoing research is essential to optimize regional control with an acceptable level of risk of treatment complications. Sentinel lymph node biopsy, if validated as an accurate method of staging the axilla in patients with breast cancer, would allow selective avoidance of regional nodal treatment and hence the associated morbidity.
The changing trends in the diagnosis and management of women with invasive breast cancer have pro... more The changing trends in the diagnosis and management of women with invasive breast cancer have prompted an examination of the need for routine axillary lymph node dissection (ALND) in women with a clinically negative axilla. The objective of this study was to examine the value of information from an ALND in guiding the selection of adjuvant systemic therapy for women with clinically node-negative breast cancer. Between January 1996 and June 2000, 447 clinically node-negative women underwent an ALND as part of their treatment for invasive breast cancer at Westmead Hospital. Three categories of risk of recurrence were devised, based on the primary tumor characteristics alone, without information from an ALND. Recommendations for adjuvant systemic therapy with and without information from an ALND were compared, and the frequency of change was calculated. Overall, 12% of women had their treatment recommendation altered by their pathologic nodal status based on the model treatment algorithm. For women in the low-risk category (pathologic tumor size &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/=10 mm, grade 1, lymphovascular invasion [LVI] negative, and estrogen receptor [ER] positive), 17% of those less than 50 years old and 14% of those 50-69 years old would have a shift in their treatment recommendations based on the pathologic nodal status. In addition, 13% of the women less than 50 years old and 10% of those 50-69 years old were recommended for more intensive chemotherapy on the basis of four or more involved nodes. For women in the high-risk category (pathologic tumor size greater than 20 mm or greater than 10 mm associated with any unfavorable prognostic factor [grade 3, LVI, or negative ER]), 19% of those less than 50 years old and 18% of those 50-69 years old were recommended for more intensive chemotherapy. Information from ALND did not alter the treatment recommendation for women &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=70 years old, as they were not recommended chemotherapy in the model algorithm. If women &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=70 years old who were node positive and had an ER-negative tumor were recommended chemotherapy, 14% in the high-risk category would have had their treatment recommendation altered as a result of the information from ALND. The continued utilization of ALND is appropriate in women less than 70 years old in the high-risk category. In other patients less than 70 years old, the pathologic nodal status is of value in guiding the…
The purpose of this study was to evaluate the capabilities of a kilovoltage (kV) on-board imager ... more The purpose of this study was to evaluate the capabilities of a kilovoltage (kV) on-board imager (OBI)-equipped linear accelerator in the setting of on-line verification imaging for external-beam partial breast irradiation. Available imaging techniques were optimized and assessed for image quality using a modified anthropomorphic phantom. Imaging dose was also assessed. Imaging techniques were assessed for physical clearance between patient and treatment machine using a volunteer. Nonorthogonal kV image pairs were identified as optimal in terms of image quality, clearance, and dose. After institutional review board approval, this approach was used for 17 patients receiving accelerated partial breast irradiation. Imaging was performed before every fraction verification with online correction of setup deviations >5 mm (total image sessions ؍ 170). Treatment staff rated risk of collision and visibility of tumor bed surgical clips where present. Image session duration and detected setup deviations were recorded. For all cases, both image projections (n ؍ 34) had low collision risk. Surgical clips were rated as well as visualized in all cases where they were present (n ؍ 5). The average imaging session time was 6 min, 16 sec, and a reduction in duration was observed as staff became familiar with the technique. Setup deviations of up to 1.3 cm were detected before treatment and subsequently confirmed offline. Nonorthogonal kV image pairs allowed effective and efficient online verification for partial breast irradiation. It has yet to be tested in a multicenter study to determine whether it is dependent on skilled treatment staff.
Journal of Medical Imaging and Radiation Oncology, 2011
The purpose of the study was to determine if multi-field inverse-planned intensity-modulated radi... more The purpose of the study was to determine if multi-field inverse-planned intensity-modulated radiation therapy (IMRT) improves on the sparing of organs at risk (heart, lungs and contralateral breast) when compared with field-in-field forward-planned RT (FiF). The planning CT scans of 10 women with left-sided breast cancer previously treated with whole-breast RT on an inclined breast board with both arms supported above the head were retrieved. The whole breast planning target volume (PTV) was defined by clinical mark-up and contoured on all relevant CT slices as were the organs at risk. For each patient, three plans were generated using FiF, five- and nine-field inverse-planned IMRT, all to a total dose of 50 Gy to the whole breast. Mean and maximum doses to the organs at risk and the homogeneity index (HI) of the whole-breast PTV were compared. The mean heart dose for the FiF plans was 2.63 Gy compared with 4.04 Gy for the five-field and 4.30 Gy for the nine-field IMRT plans, with no significant differences in the HI of the whole-breast PTV in all plans. The FiF plans resulted in a mean contralateral breast dose of 0.58 Gy compared with 0.70 and 2.08 Gy for the five- and nine-field IMRT plans, respectively. FiF resulted in a lower mean heart and contralateral breast dose with comparable HI of the whole-breast PTV in comparison with inverse-planned IMRT using five or nine fields.
Background: Patients with supraclavicular metastases at diagnosis of breast cancer were classifie... more Background: Patients with supraclavicular metastases at diagnosis of breast cancer were classified between 1987 and 2002 as having stage M1 breast cancer according to the tumor-node-metastasis (TNM) system. The 2003 edition of the TNM staging guidelines has classified such patients as having stage IIIC disease. To determine relative prognosis, we compared long-term survival in a population-based cohort of patients with isolated supraclavicular metastases (nodal-M1) to outcomes of patients with stage IIIB or M1 (other) disease at presentation. Materials and Methods: Among patients with breast cancer and known tumor stage referred to the British Columbia Cancer Agency from 1976 to 1985, 336 IIIB, 233 M1, and 51 nodal-M1 patients were identified. Actuarial overall and breast cancer–specific survival rates were determined to 20 years. Results: Overall survival at 20 years was 13.2% for nodal-M1 cases (95% confidence interval [CI], 5% to 26%), 9.4% for IIIB cases (95% CI, 6% to 14%), and...
There have been significant technological and technical advances in radiotherapy over the last 20... more There have been significant technological and technical advances in radiotherapy over the last 20 years. This paper presents the pertinent advances and examines their application in contemporary breast cancer (BC) radiotherapy, particularly for reducing the long-term toxicity, using intensity-modulated radiation therapy, image-guided radiation therapy, and management of breathing motion. These modern technologies and techniques enable precise delivery of a highly conformal radiation dose distribution to the target volume in real-time, to optimise tumour control, and minimise treatment toxicity. They have been used for the treatment of BC in selected centres around the world. Although there is insufficient high-level evidence to support their routine application in BC at present, implementation of these technologies has been shown to be feasible, and could result in clinically meaningful long-term benefits for selected patients with BC.
Background and purpose: Accurate quantification of the relatively small radiation doses delivered... more Background and purpose: Accurate quantification of the relatively small radiation doses delivered to untargeted regions during breast irradiation in patients with breast cancer is of increasing clinical interest for the purpose of estimating long-term radiation-related risks. Out-of-field dose calculations from commercial planning systems however may be inaccurate which can impact estimates for long-term risks associated with treatment. This work compares calculated and measured dose out-of-field and explores the application of a correction for leakage radiation. Materials and methods: Dose calculations of a Boltzmann transport equation solver, pencil beam-type, and superposition-type algorithms from a commercial treatment planning system (TPS) were compared with in vivo thermoluminescent dosimetry (TLD) measurements conducted out-of-field on the contralateral chest at points corresponding to the thyroid, axilla and contralateral breast of eleven patients undergoing tangential beam radiotherapy for breast cancer. Results: Overall, the TPS was found to under-estimate doses at points distal to the radiation field edge with a modern linear Boltzmann transport equation solver providing the best estimates. Application of an additive correction for leakage (0.04% of central axis dose) improved correlation between the measured and calculated doses at points greater than 15 cm from the field edge. Conclusions: Application of a correction for leakage doses within peripheral regions is feasible and could improve accuracy of TPS in estimating out-of-field doses in breast radiotherapy.
International Journal of Radiation Oncology*Biology*Physics, 2001
Purpose: Axillary dissection (AD) provides staging information and guides adjuvant treatment for ... more Purpose: Axillary dissection (AD) provides staging information and guides adjuvant treatment for patients with breast cancer. The impact of AD on breast cancer survival is unclear. This study examines age-related variations in the use of AD and analyzes survival in women with T1-T2 breast cancer according to age and AD use. Data from the Breast Cancer Outcomes Unit database was analyzed for 7,134 women aged 50ϩ referred to the British Columbia Cancer Agency from 1989-1998 with invasive T1-T2, M0 breast cancer. Primary tumor characteristics and systemic therapy use were compared using chi-square tests for women who were treated with vs without AD (ADϩ vs AD-) according to three age groups: 50-64, 65-74, and 75ϩ. Five-year actuarial breast cancer specific and overall survival were calculated using life table analysis. Comparisons of survival between ADϩ vs AD-patients were performed using Wilcoxon statistics. Results: Among 7,134 women, 47% (nϭ3,329) were aged 50-64, 34% (nϭ2,434) were aged 65-74, and 19% (nϭ1,371) were aged 75ϩ. AD was performed in 91% (nϭ6,485) of all patients. AD was omitted more frequently with advancing age (4% vs 9% vs 22% in women aged 50-64, 65-74 and 75ϩ respectively, pϽ.001). Tumor Characteristics in AD-vs ADϩ Patients: Among women aged 50-64, AD-and ADϩ patients had similar distributions of T2 tumors (29% vs 35%, pϭ.21) and grade III disease (33% vs 37%, pϭ.20). Among women in the older age groups, AD-patients had fewer T2 tumors (age 65-74: 20% T2 vs 32% T2, pϽ.001 and age 75ϩ: 27% T2 vs 40% T2, pϽ.001) and were less likely to have grade III disease (age 65-74: 21% gIII vs 32% gIII, pϽ.001 and age 75ϩ: 18% gIII vs 27% gIII, pϭ.001). Lymphovascular invasion was found less frequently in AD-patients: (age 50-64: 25% vs 35%, pϭ.03, age 65-74: 16% vs 32%, pϽ.001, and age 75ϩ: 24% vs 30%, pϭ.04). Estrogen receptor positivity was similar between ADand ADϩ patients (age 50-64: 82% vs 76%, pϭ.18, age 65-74: 85% vs 81%, pϭ.11, and age 75ϩ: 88% vs 86%, pϭ.29). Systemic Therapy Use: Overall, 42% did not receive any systemic therapy, 42% received Tamoxifen only, 7% received chemotherapy only, and 8% received both Tamoxifen and chemotherapy. The proportions of AD-and ADϩ patients who received systemic therapy were: age 50-64: 53% vs 60%, pϭ.36, age 65-74: 57% vs 56%, pϭ.73, and age 75ϩ: 57% vs 54%, pϭ.32. Clinical Outcome: Five-year actuarial breast cancer specific survival and overall survival according to age and AD use are summarized in Table . Actuarial breast cancer specific survival was lower in AD-women aged 65-74 (82% vs 88%, pϭ.04) but was similar in AD-and ADϩ women aged 50-64 and 75ϩ. Actuarial overall survival was lower in AD-vs ADϩ women in all three age groups: age 50-64: 80% vs 86%, pϭ.06, age 65-74: 68% vs 82%, pϭ.0004, and age 75ϩ: 60% vs 68%, pϭ.03. Axillary dissection was more frequently omitted with advancing age. The omission of AD did not impact breast cancer specific survival in women aged 50-64 or aged 75ϩ but was associated with lower breast cancer specific survival in women aged 65-74 despite similar rates of systemic therapy use.
Background This study compared the application of the St Gallen 2001 classification with a risk i... more Background This study compared the application of the St Gallen 2001 classification with a risk index developed at the New South Wales Breast Cancer Institute (BCI Index) for women with node-negative breast cancer treated without adjuvant systemic therapy. Methods The BCI risk categories were constructed by identifying combinations of prognostic indicators that produced homogeneous low-, intermediate- and high-risk groups using the same variables as in the St Gallen classification. Results The BCI low-risk category consisted of women aged 35 years or more with a grade 1 oestrogen receptor (ER)-positive tumour 20 mm or less in diameter, or with a grade 2 ER-positive tumour of 15 mm or less. This category constituted 40·1 per cent of patients, with a 10-year distant relapse-free survival (DRFS) rate of 97·2 per cent. The BCI intermediate-risk category included women aged 35 years or more with a grade 2 ER-positive tumour of diameter 16–20 mm, or a grade 1 or 2 ER-negative tumour measu...
Background The 1998 St Gallen classification was devised to guide clinicians in the use of adjuva... more Background The 1998 St Gallen classification was devised to guide clinicians in the use of adjuvant systemic therapy for women with early breast cancer. In this study, the classification was applied to a historical group of patients with node-negative breast cancer who were treated without adjuvant therapy. Methods The St Gallen classification was applied to 421 women with breast cancer treated with conservative surgery and radiotherapy alone between 1979 and 1994. Primary tumour characteristics were reviewed centrally. Results When the most stringent version of the St Gallen classification was applied (grade 2 or 3 tumours classified as ‘high risk’), only 10 per cent of patients were ‘low risk’, with a 10-year distant relapse-free survival (DRFS) rate of 100 per cent, and 15 per cent were at ‘intermediate risk’ (10-year DRFS rate of 94 per cent). The high-risk group (75 per cent of women) had a 10-year DRFS rate of 77 per cent (P < 0·01). If the St Gallen classification had been...
Rates and risk factors of local, axillary and supraclavicular recurrences can guide patient selec... more Rates and risk factors of local, axillary and supraclavicular recurrences can guide patient selection and target for postmastectomy radiotherapy (PMRT). Patients and methods: Local, axillary and supraclavicular recurrences were evaluated in 8106 patients enrolled in 13 randomized trials. Patients received chemotherapy and/or endocrine therapy and mastectomy without radiotherapy. Median follow-up was 15.2 years. Results: Ten-year cumulative incidence for chest wall recurrence of >15% was seen in patients aged <40 years (16.1%), with ≥4 positive nodes (16.5%) or 0-7 uninvolved nodes (15.1%); for supraclavicular failures >10%: ≥4 positive nodes (10.2%); for axillary failures of >5%: aged <40 years (5.1%), unknown primary tumor size (5.2%), 0-7 uninvolved nodes (5.2%). In patients with 1-3 positive nodes, 10-year cumulative incidence for chest wall recurrence of >15% were age <40, peritumoral vessel invasion or 0-7 uninvolved nodes. Age, number of positive nodes and number of uninvolved nodes were significant parameters for each locoregional relapse site. PMRT to the chest wall and supraclavicular fossa is supported in patients with ≥4 positive nodes. With 1-3 positive nodes, chest wall PMRT may be considered in patients aged <40 years, with 0-7 uninvolved nodes or with vascular invasion. The findings do not support PMRT to the dissected axilla.
European journal of cancer (Oxford, England : 1990), Jul 7, 2016
Although the benefit of adjunct digital breast tomosynthesis (DBT) is established in population s... more Although the benefit of adjunct digital breast tomosynthesis (DBT) is established in population screening, its benefit in surveillance after breast cancer treatment is not well defined. We prospectively evaluated whether the addition of DBT to digital mammography (DM) reduced the rate of indeterminate findings compared to DM alone in patients after breast cancer treatment. Patients had both DM and DBT for routine surveillance. Two-dimensional synthesised mammogram (SM) was generated for each patient from DBT data. DM, SM, and DBT images were read for each patient by one of four radiologists credentialed for DBT. We compared the rates of indeterminate findings between DM+DBT with DM alone in patients with a range of breast densities and between DM and SM. A total of 618 patients and 1069 breasts were analysed. The rates of indeterminate findings for DM+DBT versus DM alone were 10.5% and 13.1%, respectively (p=0.018). In breasts treated with surgery and radiotherapy (n=558), the corre...
To analyze the acute, late toxicity and esthetic outcome in early breast cancer patients treated ... more To analyze the acute, late toxicity and esthetic outcome in early breast cancer patients treated with hypofractionated radiotherapy (H-RT) preceded by IORT or followed by sequential boost (SB). Materials and Methods: 129 women with invasive breast cancer stages I and II received H-RT, 42.40 Gy (2.65Gy x 16 #) preceded by IORT (10 Gy in single fraction) in 53 patients (IORT/H-RT) or followed by SB (10 Gy-2.50 Gy x 4 #) in 76 patients (H-RT/SB). RTOG/EORTC toxicity scales were used to score acute and late skin toxicity and ultrasound analysis to assign a value to skin thickening. Cosmetic outcome was assessed comparing treated with untreated breast. Results: Acute skin toxicity of Grade 1, 2 or 3 was experienced by 58.5%, 3.7% and 0% of IORT/H-RT versus 67.1%, 9.2% and 1.3% of H-RT/SB patients. After an average of 26.5 months, late skin toxicity of Grade 1 or 2 was experienced by 34% and 1.8% of IORT/H-RT versus 42.2% and 7.8% H-RT/SBpatients. Skin thickening was greater in H-RT/SB (35.3%) than in IORT/H-RT group (8.1%). Long term cosmetic outcome was excellent or good in 94.3% of IORT/H-RT and in 72.3% of H-RT/SB patients. Results were statistically significant(p<0.001). Conclusions: Respect to SB, IORT reduces the acute and late skin toxicity, improving the subjective perception of the cosmetic outcome in early breast cancer patients treated with H-RT. EP-1213 Unintended irradiation of internal mammary chain-is that enough?
Canadian journal of surgery. Journal canadien de chirurgie, 2003
Because there is no standardized technique for mapping of lymph nodes and no optimal technique fo... more Because there is no standardized technique for mapping of lymph nodes and no optimal technique for evaluating the sentinel node, we decided to evaluate practice patterns for sentinel-node biopsy (SNB) for breast cancer in British Columbia 5 years after its introduction in 1996. We carried out mail and telephone surveys of general surgeons performing at least 1 SNB (n = 28) or not performing SNB (n = 50), and carried out telephone surveys or on-site visits with pathologists (n = 7) and nuclear medicine physicians (n = 5) from institutions supporting SNB in the province. We collected data on training, perceived indications and techniques for the surgical, imaging and pathologic assessments of SNB to obtain data on practice patterns in 2001 and the degree of consistency among surgeons and institutions involved in performing SNB and reasons for not adopting the SNB technique. By 2001, SNB was incorporated into the practice of 19% of surgeons (28 of 150) performing breast cancer surgery ...
The purpose of this article was to review the patterns and morbidity of regional recurrence (RR) ... more The purpose of this article was to review the patterns and morbidity of regional recurrence (RR) in patients with early breast cancer, efficacy of salvage therapy for RR, and complications of regional nodal treatment. A retrospective evaluation of 1,158 patients with stage I or stage II breast cancer treated with conservative surgery and radiotherapy (RT) between 1979 and 1994 was performed. Seven hundred fifty patients underwent axillary surgery, and 229 patients received RT as their only treatment of the regional lymphatics. Regional nodal RT was given to 168 patients who also had axillary surgery. The regional lymphatics of 11 patients were not treated. The patterns and morbidity of RR, relapse management, and complications related to regional nodal treatment were reviewed from the patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; records. With a median follow-up of 88 months, a total of 31 patients (2.7%) developed a RR. Nine of 31 patients (29%) with an RR experienced significant morbidity, including pain, fungating tumor, dysphagia, dyspnoea, and/or sensory motor changes at diagnosis. Nineteen patients (61%) had symptomatic residual or progressive regional disease after salvage therapy at last follow-up or death. Six of nine patients (67%) who developed an isolated axillary recurrence and underwent salvage surgery had no further axillary recurrence. The addition of regional nodal RT to breast irradiation significantly increased the incidence of symptomatic pneumonitis (1% without regional nodal RT and 4% with regional nodal RT, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Combined axillary dissection and nodal irradiation resulted in a significantly higher incidence of arm edema compared with either alone (9.5% with axillary dissection, 6.1% with RT to the axilla and supraclavicular fossa, and 31% with combined modality therapy, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001). Five of 380 patients (1%) who received RT to the axilla and/or supraclavicular fossa developed a transient brachial plexus neuropathy. Although RR was uncommon in patients treated with axillary surgery and/or regional nodal irradiation, salvage therapy failed to eradicate the recurrence in approximately two thirds of the patients with a RR. Ongoing research is essential to optimize regional control with an acceptable level of risk of treatment complications. Sentinel lymph node biopsy, if validated as an accurate method of staging the axilla in patients with breast cancer, would allow selective avoidance of regional nodal treatment and hence the associated morbidity.
The changing trends in the diagnosis and management of women with invasive breast cancer have pro... more The changing trends in the diagnosis and management of women with invasive breast cancer have prompted an examination of the need for routine axillary lymph node dissection (ALND) in women with a clinically negative axilla. The objective of this study was to examine the value of information from an ALND in guiding the selection of adjuvant systemic therapy for women with clinically node-negative breast cancer. Between January 1996 and June 2000, 447 clinically node-negative women underwent an ALND as part of their treatment for invasive breast cancer at Westmead Hospital. Three categories of risk of recurrence were devised, based on the primary tumor characteristics alone, without information from an ALND. Recommendations for adjuvant systemic therapy with and without information from an ALND were compared, and the frequency of change was calculated. Overall, 12% of women had their treatment recommendation altered by their pathologic nodal status based on the model treatment algorithm. For women in the low-risk category (pathologic tumor size &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;/=10 mm, grade 1, lymphovascular invasion [LVI] negative, and estrogen receptor [ER] positive), 17% of those less than 50 years old and 14% of those 50-69 years old would have a shift in their treatment recommendations based on the pathologic nodal status. In addition, 13% of the women less than 50 years old and 10% of those 50-69 years old were recommended for more intensive chemotherapy on the basis of four or more involved nodes. For women in the high-risk category (pathologic tumor size greater than 20 mm or greater than 10 mm associated with any unfavorable prognostic factor [grade 3, LVI, or negative ER]), 19% of those less than 50 years old and 18% of those 50-69 years old were recommended for more intensive chemotherapy. Information from ALND did not alter the treatment recommendation for women &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=70 years old, as they were not recommended chemotherapy in the model algorithm. If women &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;/=70 years old who were node positive and had an ER-negative tumor were recommended chemotherapy, 14% in the high-risk category would have had their treatment recommendation altered as a result of the information from ALND. The continued utilization of ALND is appropriate in women less than 70 years old in the high-risk category. In other patients less than 70 years old, the pathologic nodal status is of value in guiding the…
The purpose of this study was to evaluate the capabilities of a kilovoltage (kV) on-board imager ... more The purpose of this study was to evaluate the capabilities of a kilovoltage (kV) on-board imager (OBI)-equipped linear accelerator in the setting of on-line verification imaging for external-beam partial breast irradiation. Available imaging techniques were optimized and assessed for image quality using a modified anthropomorphic phantom. Imaging dose was also assessed. Imaging techniques were assessed for physical clearance between patient and treatment machine using a volunteer. Nonorthogonal kV image pairs were identified as optimal in terms of image quality, clearance, and dose. After institutional review board approval, this approach was used for 17 patients receiving accelerated partial breast irradiation. Imaging was performed before every fraction verification with online correction of setup deviations >5 mm (total image sessions ؍ 170). Treatment staff rated risk of collision and visibility of tumor bed surgical clips where present. Image session duration and detected setup deviations were recorded. For all cases, both image projections (n ؍ 34) had low collision risk. Surgical clips were rated as well as visualized in all cases where they were present (n ؍ 5). The average imaging session time was 6 min, 16 sec, and a reduction in duration was observed as staff became familiar with the technique. Setup deviations of up to 1.3 cm were detected before treatment and subsequently confirmed offline. Nonorthogonal kV image pairs allowed effective and efficient online verification for partial breast irradiation. It has yet to be tested in a multicenter study to determine whether it is dependent on skilled treatment staff.
Journal of Medical Imaging and Radiation Oncology, 2011
The purpose of the study was to determine if multi-field inverse-planned intensity-modulated radi... more The purpose of the study was to determine if multi-field inverse-planned intensity-modulated radiation therapy (IMRT) improves on the sparing of organs at risk (heart, lungs and contralateral breast) when compared with field-in-field forward-planned RT (FiF). The planning CT scans of 10 women with left-sided breast cancer previously treated with whole-breast RT on an inclined breast board with both arms supported above the head were retrieved. The whole breast planning target volume (PTV) was defined by clinical mark-up and contoured on all relevant CT slices as were the organs at risk. For each patient, three plans were generated using FiF, five- and nine-field inverse-planned IMRT, all to a total dose of 50 Gy to the whole breast. Mean and maximum doses to the organs at risk and the homogeneity index (HI) of the whole-breast PTV were compared. The mean heart dose for the FiF plans was 2.63 Gy compared with 4.04 Gy for the five-field and 4.30 Gy for the nine-field IMRT plans, with no significant differences in the HI of the whole-breast PTV in all plans. The FiF plans resulted in a mean contralateral breast dose of 0.58 Gy compared with 0.70 and 2.08 Gy for the five- and nine-field IMRT plans, respectively. FiF resulted in a lower mean heart and contralateral breast dose with comparable HI of the whole-breast PTV in comparison with inverse-planned IMRT using five or nine fields.
Background: Patients with supraclavicular metastases at diagnosis of breast cancer were classifie... more Background: Patients with supraclavicular metastases at diagnosis of breast cancer were classified between 1987 and 2002 as having stage M1 breast cancer according to the tumor-node-metastasis (TNM) system. The 2003 edition of the TNM staging guidelines has classified such patients as having stage IIIC disease. To determine relative prognosis, we compared long-term survival in a population-based cohort of patients with isolated supraclavicular metastases (nodal-M1) to outcomes of patients with stage IIIB or M1 (other) disease at presentation. Materials and Methods: Among patients with breast cancer and known tumor stage referred to the British Columbia Cancer Agency from 1976 to 1985, 336 IIIB, 233 M1, and 51 nodal-M1 patients were identified. Actuarial overall and breast cancer–specific survival rates were determined to 20 years. Results: Overall survival at 20 years was 13.2% for nodal-M1 cases (95% confidence interval [CI], 5% to 26%), 9.4% for IIIB cases (95% CI, 6% to 14%), and...
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